Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
Jan - 21
Feb - 7
Mar -
17 days at the VA – day 12
26 Nov2009
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 132 | Cl | 85 | BUN | 73 |
| K | 2.8 | HCO3 | 37 | creat | 2.8 |
| Blood Sugar | 205 |
Seeing this BMP yesterday showed the difference between knowledge and wisdom. For experienced clinicians, the patterns in this BMP are obvious. For many students and interns, we just have 7 numbers.
Here is how I think through this problem:
- The patient has an elevated creatinine and BUN.
- The BUN is much more elevated than the creatinine (greater than 20:1), therefore I suspect either GI bleed or significant volume contraction. I know that the patient has a stable Hgb and heme negative stool, so I strongly suspect volume contraction.
- The HCO3 is markedly elevated, supporting either metabolic alkalosis or compensation for respiratory acidosis. The patient has no history of chronic respiratory acidosis, and has no acute respiratory compromise, so metabolic alkalosis seems most likely.
- The hypokalemia supports the metabolic alkalosis theory.
- The patient recently had his bumetanide dose increased.
- The most common causes of hypokalemia metabolic alkalosis are over diuresis or gastric losses (either vomiting or NG suction).
- The mild hyponatremia also often occurs with volume contraction.
- So the story that I imagine when I see these numbers follows:
- Increased bumetanide dose, leading to hypokalemia and volume contraction. Volume contraction caused the patients symptoms.
- Gentle volume expansion relieved his symptoms.
For experienced clinicians this case and explanation was simple. I wrote today for medical students and early interns who do not yet have enough experience to understand the gestalt of the BMP. I hope my step by step explanation helps a few readers better understand BMP interpretation.
Related posts:
- My thoughts on March 8 acid-base
- 15 days at the VA – day 3
- Part 2 of the acid-base problem
- 17 days at the VA – Day 4
- AMS – an acid-base problem II
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3 Responses to 17 days at the VA – day 12
Intern
November 26th, 2009 at 9:50 am
I read your acid base posts very carefully and often I can't catch everything you say. This post was excellent because I was able to stay with you step by step to figure things out. Thank you for posting it and continue with your great work. All the best.
ram
November 26th, 2009 at 9:19 pm
I was expecting hypernatremia with volume contraction.
How volume contraction leads to hyponatremia?
Snipergirl
January 17th, 2010 at 4:23 am
@Ram – you need to differentiate volume loss from water loss.. Pure water loss will cause hypernatraemia- as in people with diabetes insipidus or increased insensible losses or those unable to consume water. Whole volume loss (ie isotonic blood or plasma) as in diuresis, haemorrhage or most common forms of volume contraction on its own should not lead to any electrolyte disturbance. However they can lead to hypernatraemia, hyponatraemia or no sodium disturbance depending on whether there is extra water loss (eg patient unable to drink) or extra water retention (ADH activation in cirrhosis, heart failure, severe volume depletion wtih water intake etc).